Quality Improvement Principles, Methods and

Tools

Marlene “Marni” Mason

MCPP Healthcare Consulting

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Marni Mason BSN, MBA

Thirty+ years in healthcare as clinician, manager and consultant Primary & specialty care clinic nurse and nursing

director – 15 years Consultant in healthcare performance

measurement and improvement – 18 years Public health performance management – since

2000 Surveyor for NCQA (10 years) and Senior Examiner

for state Baldrige Quality Award (late 1990s) Consultant for PHAB Standards Development

(2008-2009)

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Learning Objectives

In today’s learning session, the participants will develop a better understanding of:Principles of Quality Improvement Selected Quality Improvement MethodsSelected Quality Planning ToolsLearn about Rapid Cycle Improvement (RCI)

AndStart development of QI team AIM statement

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Collaborative with a Capital “C”

Systems are perfectly designed to produce the results they achieve

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IHI’s* Breakthrough Series

Also known as the Collaborative Method It is an improvement method that relies on

spread and adaptation of existing knowledge to multiple settings to accomplish a common aim

Methodology to accomplish organizational system change

*Institute for Healthcare Improvement www.ihi.org

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The Advantage of a Learning Collaborative for Improvement

Learning collaborative: a group of multi-disciplinary teams from multiple organizations which come together over the course of a year in structured meetings and phone contacts to accomplish specific learning objectives.

National experience demonstrates significant boost in pace and level of achievement of outcomes by sharing lessons learned.

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Collaborative Process (IHI)

Select Topic

Planning Group

Identify Change

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

E-mail Visits Web-site Phone Assessments

Senior Leader Reports

Outcomes Congress

A D

P

S

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Characteristics of a Collaborative Team approach Performance measures Teams from multiple organizations One for all, all for one Promotes a culture of change Standardizes practice Sustainable change

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MLC-3 Collaborative Targets

In Illinois, participation in the MLC-3 Learning Collaborative is focused on improvement in two target areas for MLC-3: Community Health Improvement Plans Chronic Disease Prevention-Obesity/Physical

Activity (reduce preventable risk factors that predispose to chronic disease)

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MLC-3 Collaborative Approach All sites receive training in:

Quality Improvement Methods & Tools Data Analysis Tools Rapid Cycle Improvement Method

Site-based teams develop implementation plan for improvement

Series of web-based phone sessions with coaching from consultant

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Principles of Quality Improvement

“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”

William Foster(many variations attributed to others)

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Performance Management

Source: Turning Point Performance Management Collaborative, 2003.

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The Quality Environment Do you have an organization-wide commitment to

assessing and continuously improving quality over time?

Do you use data to decide on improvement initiatives and to know if the improvements are successful?

Are your system decisions based on data?

Do you know if your agency is achieving its goals?

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Change vs. Improvement W. Edwards Deming stated “Of all changes

I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress.” We must become masters of improvement We must learn how to improve rapidly We must learn to discern the difference

between improvement and illusions of progress

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Principles of Quality Management

1. Know your stakeholders and what they need

2. Focus on processes

3. Use data for making decisions

4. Understand variation in processes

5. Use teamwork to improve work

6. Make quality improvement continuous

7. Demonstrate leadership commitment

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1. Know Your Stakeholders

Identify stakeholders and their needs

Set goals based on stakeholder needs

Monitor performance and satisfaction to target performance improvementopportunities

Improve or redesign how work is done

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Sector Maps for Planning – Example of Public Sector

Office of the Insurance

Commissioner

Governor / Legislature

Indian Health Service

Health Care Authority

School Boards

•Public Schools (K-12)•Private Schools (K-12)

Public Library System

Tribal Government

Employment Security Department

State Board of Health

Local Government

Local Health Jurisdictions

Department of Health

•Community & Family Health•Women, Infants & Children•Licensing Boards

Dept. of Social & Human Services

Bullets refer to examples of organizations and are not a comprehensive listing.

Rural & Community Health Centers

Health & Human Services

•Center for Disease Control & Prev.•Center-Medicaid &Medicare Srvcs•Fed. Drug•Administration

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Example of Private Sector

PurchasersConsulting Foundations

Business and worksite programs

Insurance Brokers

Health Plans

Hospitals

Media

Pharmaceutical Companies

Home Health Care

Ancillary Service Practitioners and

Groups

Providers

Professional Organizations

Funding Foundations

•Rob’t Wood Johnson

Bullets refer to examples of organizations and are not a comprehensive listing.

SNF and Nursing Homes

Primary/Specialty Medical Groups

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Example of Community-Based Sector

Service Organizations

•Thousands of community-based agencies: specific partners will be identified in each community

Community Centers

American Association of Retired Persons

Faith-based Community Organizations

Community Health Centers

•Federally Qualified Health Centers•Migrant Health Centers

Youth Associations

•YMCA / YWCA•Boys & Girls Club•Boy & Girl Scouts of America•Campfire Girls and Boys

Community-based Daycare Sites

•All ages•Birth to 3 childcare

Youth Sports Associations

•Little League•Pop Warner•Soccer, etc

United Way

Senior Centers

Communities of Color Organizations

Community Health Alliances Churches, Temples &

Mosques

Bullets refer to examples of organizations and is not a comprehensive listing.

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Example of Academic/Research Sector

State Universities

Nursing Schools

Allied Health Professional Schools & Training

Community Colleges

Pharmacy SchoolsPrivate Universities

Private Research Centers\Tribal Colleges

Bullets refer to examples of organizations and is not a comprehensive listing.

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Example of Target Populations

CONDITION Age Racial/ethnic Communities

Socio-economic/low literacy General Population

Public: Center for Medicaid & Medicare Services (CMS)

DOH -- CDRRP/DPCP Public Hospital Districts Tribal Associations Veteran’s Admin. Dept. of Defense Medicaid

DOH-Chronic Disease Risk Reduction (CDRRP)

DOH- Diabetes Prevention & Control Program (DPCP)

Tribal Assns. Indian Health Services

DOH-Chronic Disease Risk Reduction (CDRRP)

DOH- Diabetes Prevention & Control Program (DPCP)

Dept. of Veterans Affairs Maternal Support Services

Centers for Disease Control & Prevention (CDC)

Office of Insurance Governor/Legislature Dept. of Corrections Public Employees Benefit

Board Local Health Jurisdictions

Private: Qualis Health Health plans Media Inland NW Business Coal. Alternative health providers Home health Student health centers

Community Health Plans of WA – (CHPW)

Association of Black Health Care Professionals

Association of American Indian Physicians “Move It” program

Molina health plan Community Health Plans of

WA (CHPW) Disease management

vendors Critical access hospitals Home Health Washington Health

Foundation

Professional orgs Pharmaceutical. Co Medical Supply Co. Purchasers Disease mgt Hospitals Critical access hospitals Primary/specialty groups

Community: Amer. Diabetes Assoc. Juvenile Diabetes Research

Foundation (JDRF) Senior centers Service organizations Community Aging Service

Providers

Communities of color organizations

Amer. Diabetes Assoc. (ADA)

CHOICE Health Commu. Health Centers

(CHCs)

CHOICE Health Commu. Health Centers

(CHCs)

Commu. Health Centers Amer. Diabetes Assoc.

(ADA) Nutrition & Cultures Disease Management

Education Centers

Diagnosed

Academic: WSU Extension Focused research programs,

e.g. SEARCH for Diabetes in Youth

WSU Extension Focused research programs,

e.g. SEARCH for Diabetes in Youth

WA StateUniv. Extension

Allied health training UW Med school Bastyr University Nursing Schools Private Universities Pharmacology Schools Community Colleges Tribal Colleges

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2. Focus on Processes

85% of poor quality is a result of poor work processes, not of staff doing a bad job

Processes often “go wrong” at the point of the “handoff”

Attend to improving the overall process, not just one part—some of the most complex processes are the result of creating a “work around”

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Focus on Processes Advice from NCQA, JCAHO and others—

measure processes that are High-risk High-volume Problem-prone

And Can be tracked and reported as summary or

aggregate statistics

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Develop Process Flow Charts High level flow charts [6-12 steps] initially

Identify customer-supplier relationships More detailed flow charts as project unfolds

[client flow, information flow, materials flow, decision making flow]

Use for process redesign Use for adapting or adopting best practices

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The Logic of Public Health

There are fewer incidents of

foodborne illness

Conditions in the restaurant don’t

create unsafe food

Public is sold food that is safe to eat

We inspect restaurants

# of inspections

% of critical violations corrected

within 24 hours

rate of foodborne illness

# of critical violations

So that

So that

So that

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Logic Models (Many Shapes/Sizes) Connect what we do every day to why we do it Show logical links between activities and goals Link our process objectives to our outcome

objectives As long as the format is legible, logical, and it

works for you, it’s probably fine Boxes and arrows are not required New computer software is not required

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Logic Model: Any Public Health Program

Inputs Outputs Short Term Outcomes

Intermediate Outcomes

Long Term Outcomes

Resources Activities

Staff

Money Improved knowledge, beliefs, attitudes

Improved Behaviors

Program Development

Program Planning

Materials Development, Distribution

Informed, Targeted Program

Appropriate, Targeted Materials

Reduced Mortality

Reduced Morbidity

Improved Quality of Life

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3. Use Data to Make Decisions

Use performance assessment data to target improvement

Use data analysis tools to develop information

Analyze data to identify root cause

Use data to monitor performance outcomes

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Use Data to Make Decisions

Check Sheet Bar Chart Histogram Pareto Chart Control Chart Run Chart

Affinity Diagram Brainstorming Process Flow Chart Interrelational Diagraph Matrix Diagram Tree Diagram Cause and Effect

Diagram

Numerical ToolsConceptual Tools

[See Goal/QPC PH Memory Joggers]

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Use Data to Make Decisions

Brainstorming for root causes—theory generation relies on divergent thinking, no idea is a bad one… What can go wrong in the process we are

studying? Problems in hand-offs between steps Problems in execution within steps

Look at machines, materials, methods, measurements, and people

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Cause-effect or Fishbone Diagram

Exercise: Constructing a Fishbone Diagram Organizes and displays theories Encourages divergent thinking Demonstrates the complexity of the problem Encourages scientific analysis (rule-out)

Turn to page 23 in the PH Memory Jogger.

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4. Understand Variation Sources of variation include: machines, materials,

methods, measurements, people, environment Common cause variation occurs if the process is

stable—variation in data points will be random and obey a mathematical law—it is said to be in statistical control, with a large number of small sources of variation

Reacting to random variation in a process that is stable/in statistical control, it is called tampering and leads to further complexity, increasing variation and mistakes

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Understand Variation Special cause variation arises because of

specific circumstances which are not part of the process all the time and may or may not ever recur—if the recurrence is periodic, clues to the root cause may emerge

Variation can be shown in control charts with mean and standard deviation

Control charts are pictures of trend data with an extra feature—the range of variation built into the system

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Understand Variation A sentinel event is a special cause variation

requiring root cause analysis Examine specific incident(s) of special cause

variation and make changes to a single element only after very careful analysis

Need to investigate special cause variation before making any conclusions about performance level

Failure to distinguish between common and special cause variation can be hazardous to organizational performance!

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Variation Exercise

Joiner Associates – Hunter Conference exercise Attributed to Brian Joiner’s 9 year-old son

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5. Use Teamwork QI efforts need buy-in from

all stakeholders Creative ideas are needed Division of labor is needed Process often crosses

functions Solution generally affects

many

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Use Teamwork Teams should develop a clear charge and

support resources Teams should adopt working agreements

(cell phone etiquette to decision procedures) Teams should assign roles of facilitators and

recorders Team process has predictable stages that are

useful to keep in mind: Forming, Storming, Norming, Performing

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Example of Alignment Wheel

Public Health and Partners Aligned with the 10 Essential Services

ES 1: M onitor Health Status ES 10: Research

ES 9: Evaluate ES 2: Diagnose and Investigate

ES 3: Inform, Educate and Empower

ES 4: M obilize CommunityPartnerships

ES 5: Develop Policies and Plans

ES 6: Enforce Laws and Regulations

ES 7: Link People to Needed Services

ES 8: Assure a Competent Workforce

PH Program

CDC

LHJs

LHJs

Health Care

HHS

WADEPharm. AssocQualisADA

, FQHC

Faith-based, Educ. Assoc. (AARP etc),

Feds,

Schools, Professional Assoc., OIC,

OIC, Legisla-ture, Govern

DSHS / MAA

Health Plans

U.W.W.S.U

WADE Pharm.

DSHS / MAA

FQHC,Qualis,Health

V.A

U.W.,

Pharm. Co., N.I.H.

DM Ed Center

PH Program

Goal StatementGoal

Statement

Goal Statement

Goal Statement

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6. Make QI Continuous QI is a system-wide approach to assessing

and continuously improving quality of the processes and services over time See inter-relationships, not parts Understand the flow of work, not the one-time

snapshot Detail the work processes Determine cause and effect relationships Identify points of highest leverage Improve and innovate, not just change for

change’s sake

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PDCA/PDSA Cycle definition The Plan Do Check/Study Act Cycle is a trial-

and-learning method to discover what is an effective and efficient way to design or change a process

The “check” part of the cycle may require some clarification; after all, we are used to planning, doing/acting. It compels the team to learn from the data collected, its effects on other parts of the system, and under different conditions, such as different communities

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The PDSA Cycle for Learning and Improvement

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)• Plan for data collection

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

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Ongoing PDSA Cycles

PLAN

PLAN

ACT DO DO

CHECK

Self-Assessment or Accreditation

Performance Improvement

Cycle

Accreditation

Evaluate

Report/Recommend

Areas for Improvement

Target Improvements

Improvement work

Study Improvement Results

Recommend Improvement

Accreditation

PLAN

Evaluate

CHECK

Report/Recommend

Areas for Improvement

ACTDO

CHECK

ACT

Self-Assessment or Accreditation

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Make QI Continuous Use assessment to identify areas for

improvement Charge QI team and provide support

Provide QI training Use tools to understand root causes Use data for baseline and analysis Design process improvement to address root

causes Train…train…train… staff on the newly

designed process improvement

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Adopt or Adapt Model Practices Use data to identify need for improvement Identify exemplary practices in:

other local departments, Michigan state programs and other states, CDC and other national organizations,

www.naccho.org/topics/modelpractices other industries

Describe your process (Logic Model) Study the exemplary practice process Adopt or adapt as appropriate

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7. Demonstrate Leadership Commitment

Build a QI culture Connect the organization’s strategic

plan to performance improvement Know and use quality principles Encourage all staff to use quality

improvement in daily work Reward improvements Assure adequate QI infrastructure

for quality assessment and improvement activities

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What questions do you have?

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Rapid Cycle Improvement (RCI) and PDSA Cycles

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Why do we need a systematic model for improvement?

“All improvements require change but not all change will result in improvement. A primary aim of the science of improvement is to increase the chance that a change will actually result in sustained improvement from the viewpoint of those affected by the change.”

--The Improvement Guide, 1996

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Rapid Cycle ImprovementM o d e l fo r Im p ro ve m e nt

Wha t a re we trying to a c c om p lish?

Ho w will we kno w tha t a c ha nge is a n im pro vem e nt?

Ac t Pla n

DoStud y

The idea behind rapid cycle improvement is to first try a change idea on a small scale to see how it works, and then modify it and try it again until it works very well for staff and customers. Then, and only then, does a change become a permanent improvement.

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Testing a Change: Why Test?

Level of risk

Co

nfi

de

nc

e in

su

cce

ss

High

Low

Minor Major

-Smaller Scale Tests-More of them prior to implementation

Modified from Jane Taylor PhD

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Testing a Change: Why Test? Minimize risks of potential failure and of

potential adverse or unanticipated side effects

Predict how much improvement can be expected from the change

Learn how to adapt the change to conditions in the local environment

Evaluate costs and side-effects of the change Minimize resistance to implementation

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Rapid Cycle ImprovementM o d e l fo r Im p ro ve m e nt

Wha t a re we trying to a c c om p lish?

Ho w will we kno w tha t a c ha nge is a n im pro vem e nt?

Ac t Pla n

DoStud y

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What Are We Trying to Accomplish?

The first question is meant to establish an aim for improvement that focuses group effort.

Aims should be as concise as possible – sometimes it takes a few trials of testing an aim before it becomes truly focused Focus on what matters to the organization, staff

and patients Use numerical goals wherever possible Guidance and resources (e.g. tools to be used,

methods and systems to be changed)

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How Will We Know That a Change is an Improvement?

Measures and definitions are necessary to answer this question. Data is needed to evaluate and understand the

impact of changes designed to meet an aim. When shared aims and data are used, learning is

further enhanced because it can be shared. In this way, superior performance and best practices are more quickly identified and disseminated through benchmarking.

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What Change Can We Make that Will Result in an Improvement?

This step is also known as “How will we get there?”

Formulate change concepts that may improve the process outcomes

This is the who, what, when, and how of doing the actual test

It compels the team to learn from the data collected, its effects on other parts of the system, and under different conditions

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Consolidation of Relevant Knowledge and Experience

Develop a set of change concepts Definition of Change Concepts - Ideas for

interventions and actions for improvement with a greater likelihood of working based on evidence, quantitatively documented experience, and/or internal data.

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Some Sources for Improvement Interventions and Actions

Published literature in scientific journals Documented (with data) experience from other

public health agencies Internal qualitative analysis of work processes

Use qualitative analysis tools (e.g. fishbone diagrams, root cause concepts) to identify barriers

Internal quantitative analysis of work processes e.g. Pareto analysis

National experts (e.g. IHI, NACCHO, PHF, ASQ, Goal/QPC, MLC states and many others)

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Sequential Building of Knowledge Includes a Wide Range of Conditions in the Sequence of Tests

BreakthroughResults

Theories, hunches,& best practices Learning and im

provement

A P

S D

Evidence & Data

A P

S D

A P

S D

A PS D

Test on a small scale

Test a wider group

Test new conditions

Spread

Implement

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Sequential Testing….when do you move to implementation? After each PDSA…

Implement as is Abandon it Increase in scope

e.g. more clients, more programs Modify it and test again Test under different conditions

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Aims: Productivity

QualityCoordination

Access

RCI Team #4Or 4th Change

RCI Team #3 or 3rd Change

A P

S D

A P

S D

A P

S D

A P

S DA P

S DA P

S DA P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S DA P

S D

A P

S D

A P

S D

Testing Done in Multiple Change Areas in Parallel

RCI Team #2 or 2nd Change

RCI Team #1Or 1st Change

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Testing a Change Testing – Trying and adapting existing

knowledge on small scale. Learning what works in your system Testing is not permanent Often we have more failures than successes

Test on a small scale over a short period of time Have experts comment on feasibility Anticipate a sequence of tests on one change idea

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Testing a Change: Tips Move from ideas to action quickly Decrease the scope of the test

Test of oneness One stakeholder, one program, one day

As you are designing the test, ask ‘What design would enable us to do this test now, tomorrow or next week

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Implementing a Change

Implementation – Making this change a part of the day-to-day operation of the system Implement a change ONLY if it will lead to

improvement Involves more people and conditions: you will

run into more resistance and factors which require “design tweaks”

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What Can We Do Now…

… by Next Week, …by Tuesday,

…by Tomorrow …that we can learn from without

harming clients or burdening staff? Modified from Jane Taylor PhD

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Rapid Cycle Improvement–Example

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What are We Trying to Accomplish?

Increase accurate and complete reporting of CD to 80% or more of all reports by 10/07, and more than 95% by 2/08 with clear definition of complete reports. We do this in order to provide valid data for planning and program improvement

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How Will We Know When We Get There?: Measurements Increase (trended) in percent of accurately

completed CD reports Decrease in staff time to input incomplete

information Trend in overall measures in right direction

(direction of goodness indicated by arrow) Other CD reporting measures Other process measures

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What Changes Can We Make?

Data analysis of reasons for incomplete reports. Identify reasons with definitions Assure that database can capture each reason Initiate data collection process Train staff and providers in definition and reporting

process Address lack of knowledge of providers Create plan to identify high volume providers

and target for extra training

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RCI Team Planning ToolAim:

Measures

Cycle Number

Change Tested Person(s) Responsible

1 (9/4)

2 3 4 5 (10/2)

6 7 8 9 10 (11/6)

11 12 13 (11/28)

1 Data on staff cancellations to determine reasons (Pareto analysis

1a Identify reasons for staff cancellations Beth T., Margaret

1b Establish definitions of staff cancellations Bernie & Med Prov

1c Train staff and providers in definitions Donna, Beth T.

1d Pilot test in all provider practices for 7 weeks 10/9- 11/24

Beth, Margaret

Reduce staff cancellations of patient appointments to 5% or less by Dec 2006 and less than 2% by March 2007 with clear definitions of types of appointments considered staff cancellations.We do this in order to provide high quality, accessible services to our clients.

PROJECT: REDUCE PERCENT OF STAFF CANCELLATIONS (10-3-06)

3. Trend in overall measures in right direction (e.g. hospitalizations, staff and patient satisfaction)2. Assess actual increase in productivity (measured by hours of direct service) that occur as a result of reducing the percent of 1. Trend of staff cancellations in right direction.

WEEK. (1 = Sept 5)

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Data Analysis- Pareto Chart

Non-Reporting Facilities by School Type

0

10

20

30

40

50

60

70

80

90

100

CHILDCARE/PRESCHOOL Total PUBLIC Total PRIVATE Total CHARTER Total

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

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Data Analysis- Pareto Chart

Non-Reporting Schools By District

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11

8 85 4 4 4 3 3 3 3 2 2 1 1 1 1 1 0 0

7

0

10

20

30

40

50

60

70

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

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Results – Error Rate

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Results – Time Study

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Steps to Set Up a Rapid Cycle Improvement Establish a multi-disciplinary RCI team Identify a positive opinion leader Align leadership and administrative support Consolidation of relevant knowledge and

experience (national) for multiple changes Development of an overall aim statement

(using the three questions at a high level) Decide where to start and develop a strategy

for a series of rapid cycles.

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Guidance on Following the Steps

It is important not to try to write the perfect AIM statement and develop the most thorough rapid cycle strategy at the start. It is more important to start small, rapid tests of change through PDSA cycles as soon as possible. The AIM statement and strategy evolve continually as you learn from testing.

The major objective is to build organizational learning from small tests of change.

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Key Lessons from RCI

The rapid improvement work must be seen as The Work and not a separate project

Implementation and holding the gains requires integration into daily work and meetings

Start work with those interested in change Communicate what is happening persistently Provide support to providers and staff who take

on this new work

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What questions do you have?