Topic 7

1. Topic 7 Introduction to methods for quality improvement

2. 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

3. Performance requirement • know how to use a range of improvement activities and tools

4. 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

5. The science of improvement • appreciation of a system • understanding of variation • theory of knowledge • psychology W Edwards Deming

6. The Institute for Healthcare Improvement (IHI): different measures

7. Three types of measures • outcome measures • process measures • balancing measures

8. 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?

9. The model for improvement 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? ACT PLAN STUDY DO Langley, Nolan, Nolan, Norman & Provost 1999

10. The PDSA cycle Determines what changes are to be made Change or test ACT PLAN STUDY DO Summarizes what was learned Carry out the plan Langley, Nolan, Nolan Norman & Provost 1999

11. 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

12. 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

13. Two continuous improvement methods • clinical practice improvement methodology (CPI) • root cause analysis

14. Project mission Project team Ongoing monitoring Outcome Future plans Project phase • Conceptual flow of process • Customer grid • Data • fishbone • Pareto chart • run charts • SPC charts Sustaining improvement phase 1 1 month 5 Diagnostic phase Annotated run chart SPC charts Impact phase 2 4 3 Intervention phase A 2 months P S D S D 2 months S Plan a change Do it in a small test Study its effects Act on the result P A A A D A S P P S P D D The improvement process 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

15. 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) Identify appropriate interventions Implement changes identified in the diagnostic phase Undertake one or more PDSA cycles Interventions phase Decide on interventions Undertake one or more PDSA cycles

16. ACT PLAN • What changes can be made for the next cycle (adapt change, another test, implementation cycle?) • Objective • Prediction • Plan for change (who, what, when, where) • Plan for data collection (who, what, when, where) STUDY DO Complete analysis of data Compare results to predictions Summarize knowledge gained • • • • Carry out the change • Document observations • Record data 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 NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

17. PDSA cycle - single test PDSA Cycles – single test D S Changes that result in improvement S A P A A D P S P A P D S D Hunches, theories and ideas Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

18. PDSA cycle – multiple tests D S D S D S P P A A P A S S S D A D A D A P P P A P A P A P S S S D D D Test 1 Test 2 Test 3 PDSA Cycles – multiple tests NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

19. Measure impact of changes/interventions Record the results Revise the interventions Monitor impact Impact and implementation phase Impact and implementation phase • Annotated run chart • SPC charts • Other graphs Measure impact Implement the changes NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

20. Once an intervention has been introduced, the intervention and any improvements need to be sustained 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 the improvement phase Sustaining improvement phase • standardization • documentation • measurement • training Sustain the gains NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

21. 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

22. Performance requirements Know how to use a range of improvement activities and tools • flowcharts • cause and effect diagrams (Ishikawa/fishbone) • Pareto charts • run charts

23. Evidence for there being a problem worth solving At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales.

24. Flow chart of process Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince Area CNC Pain Management North Coast Area Health Service NCHI Sydney Australia Something amiss Visit to general practitioner Post anaesthetic care Surgical ward Operating theatre Investigations Allied health Surgical team Pain team Referral to surgeon Pre-op ward Discharge planner Referral to Hospital Admitted to hospital Community health/ Peripheral hospital Hospital admission Preoperative clinic Return to life Home Admissions office

25. Customer and expectations list 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 • surgical ward staff • post-op anaesthetic care staff • physiotherapy dept • dietitian • peri-operative unit staff • private hospital staff • pain team • anaesthetists • surgeons • intensivist

26. Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince Area CNC Pain Management North Coast Area Health Service NCHI Sydney Australia Cause and effect diagram Social issues Staff attitudes Complications LOS poor pain control home support mobilization wound complications often weak pain control weak/malnourished family support nutrition infection Prolonged LOS nutrition expect long LOS mobilization poor understanding of procedure general practitioner nil by mouth community health surgery little knowledge of support services family pain control locus of control colon care nurse Procedure Post discharge support Patient perception

27. 100 80 76 67 57 42 24 Pareto chart

28. PDSA cycles - implementation • surgical incision trial of transverse incision • pain control wound infusion for transverse incisions then • patient information booklet • surgeon pathway • anaesthetic pathway • ARCS clinical pathway - surgical technique - pain control - bowelprep/care - nutrition - mobilization 1 surgeon10 patients 1 surgeon1-6 patients

29. Run chart Made change here

30. 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