An Introduction to Quality Improvement

1. An Introduction to Quality Improvement Paul Harriman 11:00 – 12:00

2. Aims / Objective • To (very quickly!) give you an overview of the basics of Quality Improvement… • To work out what you don’t know so that we can work out what needs delivering in future sessions

5. Will, ideas and execution

6. What is Quality Improvement?

7. Quality: The IOM’s Six Aims High Quality care is care that is: • Safe – no needless deaths and harm • 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

8. Improvement The combination of a ‘change’ (improvement) combined with a ‘method’ (an approach or specific tools) to attain a superior outcome

9. Quality Improvement Knowledge

10. Quality Improvement Knowledge

11. “Every system is perfectly designed to get the results it gets.” Paul B. Batalden, MD Co-Founder The Institute for Healthcare Improvement Founding Director, Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice FoundingDirector, Healthcare Improvement Leadership Development The Dartmouth Institute for Health Policy and Clinical Practice Co-Founder Institute for Healthcare Improvement

12. What is a system? • a collection of processes • working together under a common set of instructions • to produce a defined output

13. What is a process? • A system of steps • Handling a piece or work • Has an input and an output • Has a supplier and a customer • SIPOC

14. Elements of a Process Staff Patients / Customers Outputs Inputs Sequence of steps Patient Process passing through a Dialysis Unit

15. Process and value stream mapping • Later

16. Quality Improvement Knowledge • Appreciation of a System • PDSA Cycles and run charts • Variation • Psychology

17. Variation • A major issue for any system If I had to reduce my message for [management] to just a few words, I’d say it all had to do with reducing variation.”W. Edwards Deming • Has 2 different types • Common cause • Special cause • Can be planned or unplanned

18. Two Types of Variation Common Cause Variation caused by chance causes, by random variation in the system, resulting from many small factors. Example: Variation in work pressures due to staffing levels, patienttransport delays, extended dialysis times Special Cause Variation caused by special circumstances or assignable cause not inherent to the system. Example: Variation in work pressures due to a cardiac arrest, power failure, fire alarm Statistically significant (not good or bad) 18

19. Run Charts vs. SPC Charts Run Chart SPC More Powerful Control lines show the degree of variation Need software Need 25+ data points • Simple • Easy to create in Excel or on paper • Less Sensitive • Only need 12-15 data points

20. Quality Improvement Knowledge

21. Maslow’s Hierarchy of Needs

23. Ownership not Buy-In ‘If you want to make true and lasting change, ask the people who do the work how to go about it’ Daren Anderson, MD VP/Chief Quality Officer Community Health Center, Inc.

24. Enable Mastery Allow autonomy Create sense of purpose How to motivate

25. Motivation Maintenance Capability Opportunity Sustained Improvement Requires behaviour change Conceptual Model - Susan Michie & Martin Wildman (Adapted) necessity Won’t concern Habitformation Routines Can’t 25

26. ‘Improvement in health care is 20% technical and 80% human’ Marjorie Godfrey, MS, RN, PhD The Dartmouth Institute for Health Policy and Clinical Practice

27. Good change?

28. The other side of change………………

30. Change Curve Motivation, Performance Time Elizabeth Kubler-Ross, 1969

31. The Everett Rogers curve

32. Quality Improvement Knowledge

34. Why Measure? If you don’t measure it how will you know that the change is an improvement? How will you know if what you are observing is not due to chance? 34

35. The Three Faces of Measurement

36. What is our global aim Uptake of shared hd care New patients in Hospital main unit Out patient department Ongoing process Patients to be expected to do certain tasks and be encouraged with choice of others. Percentage of patients doing 5 or more to increase. Patients will not be dependant unless they are unwell. We do not wish to waste any opportunity to engage

37. Key Components of a Specific Aim • Ambitious • Measureable • Operationally specific • Time-limited • How Much? • By When?

38. Measurement over time • Run charts • Simple, efficient and powerful • Plot over time + median • Rules for identifying unexpected runs • Use for WIP (queues, bed occupancy) • Statistical process control charts (SPC) • Derived from manufacturing • Plot over time; mean and control limits • Data needs to be independent • Needs 25 data points in a stable system to start

39. Quality ImprovementA structure for Improvement and some tools

40. SDSA ‘Standardise’ Quality Improvement - The structure Treatment - PDSA Diagnosis - Change Ideas Assessment

41. Continuous Improvements Change Ideas Brainstorming Change Concepts Benchmarking and visits Process/Value Stream Map Fishbone Spaghetti Diagrams Selection criteria & Multivoting Driver Diagram Global Aim Specific aim Standardise Change idea Themes ‘Post-it Frenzy’ A P S D Build a Big Room Define measures A P S D A P S D Pre-Phase Coached weekly meetings Patient stories System data Reflective learning

42. Big Room Concepts

43. Secondary Drivers Anatomy of a Driver Diagram A Primary Drivers 1 B Aim 2 ‘Multiple influences’ C Outcome 3 D ‘Cause the outcome’

44. Secondary Drivers A Non Medical Example Shop at cheaper petrol station Primary Drivers Reduce fuel price per gallon Walk to work Reduce miles driven Aim Decrease use of rapid acceleration Decrease fuel costs Increase Efficiency Inappropriate use of gears Decrease use of rapid breaking

45. Linking it all together – Rapid cycle improvement Global Aim – Increase Shared HD care in centre based HD patients PDSA 3 PDSA 2 Specific aim - patients to learn and complete 5 or more out of 14 tasks PDSA 1 PDSA 6 Measures Change ideas PDSA 5 Specific aim - increase home HD and in centre independent dialysis by 4% within Participating centres PDSA 4 Change ideas Measures

46. Linking measures to Drivers PDSA Specific Aim Global Aim We aim to improve the movement of patients across boundaries within the stroke pathway We will improve the quality of patient information in the Transfer of Care document so that it contains 100% of the information required by colleagues at the next step in the Stroke pathway” We plan to achieve this by 1st September 2016 PDSA 1 PDSA 2 PDSA 3

47. What is stakeholder analysis? • Technique to identify, engage and communicate with key stakeholders effectively • Stakeholder: anyone impacted upon, or with an interest or concern in the service. • Use SIPOC to help identify them

48. Lean Wastes • Transportation • Inventory • Motion • Waste • Over-production • Over-procesing • Defects • Skills

49. 5 Whys – Getting to the root cause The patient stayed in hospital 111 days – Why? Because they developed hospital acquired pneumonia – Why? Because they were immobile – Why? Because they fell on the ward – Why? Because they had been waiting for discharge – Why? Because there is a lack of home care provision The patient stopped wanting to learn how to programme his machine Because he was getting different information from lots of staff Because the staff were teaching in different ways Because the staff had not asked him what he had already been taught Because the staff had not all been trained to communicate in this way Because there was no standard training for staff

50. 5S