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NYU Wagner

Spring 2018

Faculty: Karen A. Scott, MD, MPH and Hillary Jalon, MSc

Meeting time: Wednesdays, 6:45- 8:25PM

Location: 194M 307, Washington Square

Faculty contact information:

The best way to reach us will be email: kas957@nyu.edu; hsj4@nyu.edu

Email us both.

Please allow 24 hours for a response.

Office hours: by specific arrangement.

Continuous Quality Improvement (CQI)

HPAM-GP 2825 and GPH-GU 2425

Introduction

This course will provide students with an introduction to the tools and methods used to produce

effective changes in improving healthcare systems. We will explore the current policy and

practice environment driving the focus on value, quality and cost. We will discuss quality

broadly, as defined by the Institute of Medicine report – including attention to safety, patient

experience, and equity. Students will engage in how to initiate quality improvement (QI) work,

using proven methodologies, and how to take QI projects to the level of widespread, sustainable

change within a clinical practice, large healthcare provider, or healthcare system. We will study

how to develop strategies to engage key stakeholders, use measurement and data, and create

communications in order to achieve change.

Prerequisites:

CORE-GP.1011, Statistical Methods for Public, NonProfit, and Health Management

HPAM-GP.4833, Health Care Management 1: Control and Organizational Design

Computer proficiency

Students lacking the prerequisites must obtain permission to enroll in this course

Required for health management specialization students.

Learning Outcomes

At the successful completion of this course, students will be able to:

Appreciate the historical evolution of healthcare quality improvement

Apply a systematic method of improving a process using a team approach

Plan for the sustainability and spread of an improvement effort

This course also addresses Core Competencies recommended by the Commission on

Accreditation for Health Management Education (CAHME) which include:

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The ability to measure, monitor and improve safety, quality, access and system/care

delivery processes in health care organizations (Assignment #1: Article Review and

Assignment #3: Aim Statement and PDSA Worksheet)

The ability to use information systems and evidence-based management principles for

problem-solving, strategic planning and decision-making, and implementing and

measuring change. (Assignment #2: Use of Analytic Tool for Problem Analysis)

The ability to synthesize evidence, and apply statistical, financial, economic and cost

effectiveness tools/techniques in organizational analysis. (Assignment #4: Run and

Control Charts)

The ability to present convincingly to individuals and groups the evidence to support a

point of view, position or recommendation. (Assignment #5 Read and Review of Article

and Assignments #6a and 6b Spread Planner)

The ability to manage teams, projects and people; to work in change oriented health care

organizations; and mentor a diverse and changing workforce. (Final Project Team

Presentation)

**Expected level of competency to be achieved is denoted above as:

(1) Basic: Foundational understanding of knowledge/skill/competency

(2) Intermediate: Student demonstrates greater depth of understanding of this

knowledge/skill/competency and can use this ability to analyze a problem

(3) Advanced: student demonstrates expertise in this knowledge/skill/competency and

can use this ability to evaluate, judge, and synthesize information.

Learning Strategies

This course is based on:

1. Discussion of current events and the common themes emerging that are affecting the delivery

of healthcare services and

2. Learning by doing, i.e., applying methods learned in class to process improvement

assignments.

3. Process analysis provides the student the opportunity to think, read, write, and present ideas

logically in an organized manner. Emphasis will be placed on oral and written

communication and working in teams.

In this course, students will take the role of a team in a specific department or service in a

healthcare organization. Students will use management tools and techniques, diagnose problems

and develop innovative, practical and cost-effective solutions to address a process needing

improvement. Assignments are geared toward analyzing a specific process that is producing a less

than optimum outcome, identifying the data required to analyze the problem, and using specific

QI tools and techniques for innovative solutions. Finally, students will work on the additional

tasks required to make a solution sustainable, or spread across an organization.

Teams

Working in teams is a critical aspect of quality improvement work. Students will be grouped

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into teams of 4-5 members during the second/third sessions of this course, and work together

throughout the term on a process improvement project. Students will select an organization, to

which at least one team member has access, and investigate a process that needs improvement.

The process you choose should be meaningful to the organization so that recommended changes

can be adapted. You must be able to collect data (concurrently or retrospectively) about the

process over time, so be sure to choose a process that is well-defined and lends itself to

measurement.

IHI Open School

This course will integrate with the IHI Open School for Health Professions, an online school for

helping students learn about quality improvement and patient safety competencies. (See below)

Course Expectations

Attend every class on time,

Read all assigned materials prior to class,

Actively participate in-class discussions and exercises,

Actively engage and work with team members to complete assignments, and

Complete online and written assignments on time.

Please discuss with us as soon as possible should you foresee difficulty in adhering to any course

expectation. All class absences must be excused in advance. Extensions for assignment

completion are granted only in cases of emergency. Please contact us by email with either

of these circumstances.

Assignments and Grading

1. Written assignments (6) -- Total 48 points.

Assignments are to be handed in via email, before midnight of due date.

2. IHI Open school learning modules (5) -- total 25 points

completion online, evidenced by printed certificate.

IHI Open School course completed past the due date without approved extension will

not be credited.

3. Final Team Project and Presentation -- total 20 points

4. Class Participation and attendance -- total 7 points

A point will be deducted for unexcused absence

Late assignments will lose 2 points per day after due date.

Final project and presentation: students will work in small teams to develop and present a

specific improvement project, including the results of initial steps to test a change, data to

support improvement, and planning to take a project to a new location or team (spreading

improvement).

Wagner School Academic Code:

All students should review the Wagner School policies on academic honesty and grading by

visiting the NYU Wagner School web site at: https://wagner.nyu.edu

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Required Articles

Posted on NYU Classes

Required Online Courses

IHI Open School online courses are free to students and provide important lessons in patient

safety, quality improvement and leadership.

Completion of the selected courses (and due dates) as noted in the syllabus is required. To receive

credit for completion:

1. Generate the course completion certificate (you must complete the evaluation at the end of

the course to generate the certificate)

2. Submit the certificate through the NYU Classes site under “Assignment” as an attachment.

Written Assignments

There are two individual assignments and four team assignments.

Individual (10 points each)

#1. One page analysis and response: “What is Quality Improvement?” Based on the editorial by

Batalden and Davidoff, the recommended resources, and any other research as desired, please

write one page describing what you view or understand to be key features or components

necessary for effective quality improvement work. Explain how well these features are currently

integrated into healthcare systems, and at least 2 options for strengthening that integration.

#5. Case Review and Critique: Pronovost P, Needham D, Berenholtz S, Sipopoli D, Haitao C,

Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C.

An intervention to decrease catheter-related bloodstream infections in the ICU. New England

Journal of Medicine 2006, 355(26): 2725-2732.

Apply what you have learned from this course to date to a real case.

From what you have learned in the Continuous Quality Improvement course about using the

Model for Improvement to initiate and produce change, please read the article by Pronovost, et al,

and assess the strengths and weaknesses of the authors’ approach this issue. As you pull together

your analysis, please use the questions below as a guide: 1. Describe your thoughts about the interventions Pronovost and colleagues used in this endeavor.

What are the pros and cons of each part of the intervention that hospitals were asked to

implement?

2. What aspects of the team composition do you think were positive? What would you have changed

about the team composition, and why? What other disciplines might you have considered to

include?

3. What are your thoughts about the measurement strategy in this effort? Would you have included

process measures in the design? If you would have approached the measurement strategy

differently, please describe this here.

4. What do you think are some of the major strengths and successes of this work? What do you think

are some of the major limitations of this work?

5. Please describe any other thoughts you might have about this effort, and how you think this type

of endeavor has advanced the field of quality improvement and patient safety over the past 10

years.

Team (7 points each)

For each of the following assignments, please include a cover page stating your team name,

members, and “problem” to be improved.

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#2. Problem analysis: Select one analytic tool for analyzing your problem, prepare assessment of

problem using that tool, and explain why that tool selected.

#3. Model for Improvement: Complete Aim Statement and PDSA Worksheets.

#4. Run chart/control chart. Run charts are graphs of data taken over time. Control charts build

on run charts and are a key tool used to display variation in the process, and identify the presence

or absence of special or common cause variation. Gather data and prepare a run chart; add upper

and lower control limits to turn it into a control chart. Prepare a written statement of your

analysis.

#6 a and b. Spread planner. Complete the template provided to plan a process for spreading an

improvement from an initial project. The planner will guide you to consider the intervention,

communication plans, creating a social network for change, measurement and leadership.

Course content and schedule – posted on NYU Classes/Syllabus

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Week Topic/Class

agenda

Required Reading/IHI Course Suggested reading/resources Assignments

Week 1

1/24/18

Introduction to

course

Quality

Improvement and

Healthcare Policy

Editorial:

“What is “quality improvement’ and how

can it transform healthcare?” Paul

Batalden and Frank Davidoff. Quality

and Safety in Healthcare 2007;16;2-3.

Article:

The Triple Aim: Care, Health, and Cost. Donald

M. Berwick, Thomas Nolan and John

Whittington. Health Affairs May 2008; Vol 27,

no 3:759-769.

2014 National Healthcare Quality & Disparities

Report. June 2015. Agency for Healthcare

Research and Quality, Rockville, MD. Retrieved

from:

http://www.ahrq.gov/research/findings/nhqrdr/nh

qdr14/index.html

www.whynotthebest.org

The Habits of an Improver. By Bill Lucas and

Hadjer Nacer. The Health Foundation. October

2015

Review instructions for

IHI Open School

course on NYU Classes

****INSTRUCTIONS

WILL BE POSTED

AS SOON AS

AVAILABLE,

PRIOR TO WEEK 2

(Individual)

Assignment #1

Article Review

One page “What is

Quality Improvement”

DUE 2/7/18

Week 2

1/31/18

How do we

improve?

Class organizes

into Teams; discuss

first Team activity

IHI Module QI 101: Introduction to

Healthcare Improvement

Chapter 1 in The Improvement Guide, G.

Langley, R. Moen, Kevin Nolan, et al.

2nd edition. 2009; pp 15-25

IOM 2001 Exec summary, Crossing the Quality

Chasm: A New Health System for the 21st

Century.

Retrieved from:

https://www.ncbi.nlm.nih.gov/books/NBK22227

1/

InInitial

2

Week Topic/Class

agenda

Required Reading/IHI Course Suggested reading/resources Assignments

Week 3

2/07/18

Understanding the

Problem: Analytic

Tools

Provost L, Bennett B. What's your

theory? Driver diagram serves as tool for

building and testing theories for

improvement. Quality Progress. 2015

Jul:36-43.

Fishbone (Ishikawa) Diagram:

www.asq.org

Pareto charts: www.asq.org

Failure Modes and Effects Analysis:

www.ihi.org

IHI Module PS 201: Root Cause,

System Analysis

The improvement Guide. G. Langley, R. Moen,

Kevin Nolan, et al. 2nd edition. 2009

Appendix B-Tools and Methods to Support

Improvement

Joint Commission Framework for Conducting a

Root Cause Analysis; link:

https://www.jointcommission.org/framework_for

_conducting_a_root_cause_analysis_and_action_

plan/

(Team) Assignment #2

Select one analytic tool

for analyzing your

problem. Prepare one

page assessment of

problem using that tool.

DUE 2/21/18

Week 4

2/14/18

Model for

Improvement:

PDSA Cycles

Chapters 4 and 5, pp 75- 108 in The

Improvement Guide

IHI QI 102: How to Improve with the

Model for Improvement

Week 5

2/21/18

Model for

improvement:

Measurement and

Data

IHI QI 103: Testing and Measuring

Changes with PDSA Cycles

(Team) Assignment #3

Complete Aim

Statement, and PDSA

Worksheet

DUE 3/7/18

Week 6

2/28/18

Using Data;

High Reliability

Organizations

The path to safe and reliable

healthcare. Leonard MW, Frankel A.

Patient Educ Couns. 2010;80:288-292

High Reliability. Sept. 2015

InInitial

3

Week Topic/Class

agenda

Required Reading/IHI Course Suggested reading/resources Assignments

www.Psnet.ahrq.gov

Week 7

3/7/18

Spreading

Improvements:

Community

Health

Improvement

Guest Lecture

“A Framework for Spread” Massoud

MR, Nielsen GA, Nolan K, Schall M,

Sevin C. IHI Innovation Series white

paper. www IHI.org

The Improvement Guide “Spreading

improvements” pp 210-216. Langley et

al 2009

Accelerating the Spread of Good

Practice. Section 8. Communicating to

make it happen, pp 65-78 Sarah W.

Fraser 2002

Spreading improvement across your health

system, editors Kevin Nolan and Marie Schall.

2006 Chapter 5 -“Redesigning Chronic illness

care in a public hospital system.”

Karen Scott Collins, MD, MPH and Reba

Williams, MD. Chapter 5 (pp 77-94)

Sodzi-Tettey S, Twum-Danso NAY, Mobisson-

Etuk LN, Macy LH, Roessner J, Barker PM.

Lessons Learned from Ghana’s Project Fives

Alive! A practical guide for designing and

executing large-scale improvement initiatives.

Cambridge, Massachusetts: Institute for

Healthcare Improvement; 2015. (Available at

www.ihi.org) pp 1-23.

(Team) Assignment #4

Complete Run Chart

and Control Chart

DUE 3/21/18

Week 8

3/14/18

SPRING BREAK

InInitial

4

Week Topic/Class Required Reading/IHI Course Suggested Reading/Resources Assignment

Week 9

3/21/18

Effective Teams and

Dynamics on

Interdisciplinary

Teams

Teaming, How organizations

learn, innovate and compete in

the knowledge economy. Chapter

3 – “The Power of Framing” pp

83-113. Amy C. Edmondson

(Individual)

Assignment #5

Read and review of

article:

Pronovost P,

Needham D,

Berenholtz S,

Sipopoli D, Haitao

C, Cosgrove S,

Sexton B, Hyzy R,

Welsh R, Roth G,

Bander J, Kepros J,

Goeschel C. An

intervention to

decrease catheter-

related bloodstream

infections in the

ICU. New England

Journal of Medicine

2006, 355(26):

2725-2732.

DUE 4/4/18

5

Week Topic/Class Required Reading/IHI Course Suggested Reading/Resources Assignment

Week 10

3/28/18

Using Improvement

Tools and Spreading

Improvements:

Guest Lecture

The Improvement Guide,

“Spreading Improvements” pp

195-205;

QI 201: Planning for Spread:

From Local Improvement to

System-Wide Change

Batalden, P. BMJ Quality and

Safety 2014; 23:4-7 “Making

improvement interventions happen-

the work before the work: four

leaders speak”

(Team) Assignment

#6a

Complete Sections

1-2 of Spread

planner

Completed Spread

Planner (Sections 1

through 5; Sections

3-5 will be given

during Week 12

class)

DUE 4/18/18

Week 11

4/4/18

HIT and Quality

Guest Speaker-

Meaningful Use Regulations and

Description:

https://www.healthit.gov/policy-

researchers-

implementers/meaningful-use-

regulations

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Week Topic/Class Required Reading/IHI Course Suggested Reading/Resources Assignment

Week 12

4/11/18

Patient Centered

Care Linked with

Quality Improvement

Guest Lecture-

“Patient Centered Care: What

does it take?” Dale Shaller,

October 2007. The

Commonwealth Fund.

www.commonwealthfund.org

Presentation: “Sorting Fact from

Fiction: The Value of Patient

Experience Measurement.” Paul

Cleary, PHD, and Marc Elliot,

PhD October 2015.

www.Caphs.ahrq.gov

Issue Brief: “How Two Provider

Groups are using the CAHPS

Clinician and Group survey for

Quality Improvement” 2014.

“Patient Centered Care: What it

Means and How to Get There”

James Rickert. Health Affairs Blog.

January 24, 2012.

(Team) Assignment

#6b

Complete sections

3-5 of spread

planner

Submit completed

spread planner

(Sections 1 through

5) DUE 4/18/18

Final Project

Instructions Given

for Final Class

Team Presentation

DUE on 4/25/18

Week 13

4/18/18

Patient Safety

Guest Lecture-

Update on Safety Culture. A.

Frankel and M. Leonard. July-

Aug 2013 www.Psnet.ahrq.gov

Boysen PG. Just Culture/A

Foundation for Balanced

Accountability and Patient Safety

Ochsner J. 2013 Fall;13(3):400-

06.

AHRQ Hospital Survey on Patient

Safety Culture, web site link:

https://www.ahrq.gov/sops/quality-

patient-

safety/patientsafetyculture/index.html

Week 14

4/25/18

Class Team

Presentations

Groups 1 through 3

Submit Final Class

Team Presentation

4/25/18

Week 15

5/2/18

Class Team

Presentations Groups

4 and 5