Quality Improvement Principles, Methods and Tools

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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 todays learning session, the participants
  will develop a better understanding of
• Principles of Quality Improvement
• Selected Quality Improvement Methods
• Selected Quality Planning Tools
• Learn about Rapid Cycle Improvement (RCI)
• And
• Start 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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IHIs 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)
Participants
Select Topic
Prework
P
Identify Change Concepts
P
P
A
D
A
D
A
D
S
S
S
Planning Group
Outcomes Congress
LS 1
LS 2
LS 3
Supports E-mail Visits Web-site Phone
Assessments Senior Leader Reports
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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 Ive
  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

• Know your stakeholders and what they need
• Focus on processes
• Use data for making decisions
• Understand variation in processes
• Use teamwork to improve work
• Make quality improvement continuous
• 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

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

• Health Human Services
• Center for Disease Control Prev.
• Center-Medicaid Medicare Srvcs
• Fed. Drug
• Administration

Employment Security Department
Tribal Government

• Department of Health
• Community Family Health
• Women, Infants Children
• Licensing Boards

Local Health Jurisdictions
Health Care Authority
Rural Community Health Centers
Dept. of Social Human Services
Local Government
Public Library System
Indian Health Service
State Board of Health
Bullets refer to examples of organizations and
are not a comprehensive listing.
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Example of Private Sector
Purchasers
Consulting Foundations
Hospitals
Professional Organizations
Home Health Care
Health Plans

• Funding Foundations
• Robt Wood Johnson

Pharmaceutical Companies
Primary/Specialty Medical Groups
Providers
Business and worksite programs
SNF and Nursing Homes
Ancillary Service Practitioners and Groups
Insurance Brokers
Media
Bullets refer to examples of organizations and
are not a comprehensive listing.
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Example of Community-Based Sector

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

United Way
Community Centers

• 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

Senior Centers
Faith-based Community Organizations
Communities of Color Organizations

• Community-based Daycare Sites
• All ages
• Birth to 3 childcare

American Association of Retired Persons

• Youth Sports Associations
• Little League
• Pop Warner
• Soccer, etc

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
Community Colleges
Tribal Colleges
State Universities
Private Research Centers\
Private Universities
Pharmacy Schools
Nursing Schools
Allied Health Professional Schools Training
Bullets refer to examples of organizations and is
not a comprehensive listing.
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Example of Target Populations
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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 partsome 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 othersmeasure
  processes that are
• High-risk
• High-volume
• Problem-proneAnd
• 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
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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, its probably fine
• Boxes and arrows are not required
• New computer software is not required

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Logic Model Any Public Health Program
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(No Transcript)
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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
Numerical Tools
Conceptual Tools

• 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

See Goal/QPC PH Memory Joggers
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Use Data to Make Decisions

• Brainstorming for root causestheory 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
  stablevariation in data points will be random
  and obey a mathematical lawit 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
  recurif 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 featurethe 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 Joiners 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
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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
  changes 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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Plan
Act

• Objective
• Questions and
• predictions (why)
• Plan to carry out the cycle
• (who, what, where, when)
• Plan for data collection

• What changes
• are to be made?
• Next cycle?

The PDSA Cycle for Learning and Improvement
Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize
• what was
• learned

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

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Ongoing PDSA Cycles
PLAN
PLAN
Target Improvements
PLAN
Accreditation
Accreditation
DO
ACT
DO
ACT
ACT
DO
Improvement work
Evaluate
Recommend
Areas for Improvement
Areas for Improvement
Evaluate
Improvement
CHECK
CHECK
CHECK
Report/Recommend
Study Improvement Results
Report/Recommend
Self-Assessment or Accreditation
Self-Assessment or Accreditation
Performance Improvement Cycle
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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
• Traintraintrain 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 organizations 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 Improvement
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?
Low
-Smaller Scale Tests -More of them prior to
implementation
Confidence in success
High
Major
Level of risk
Minor
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 Improvement
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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
A
P
Evidence Data
S
D
Spread Implement
A
P
S
D
A
P
S
D
Test new conditions
A
P
Learning and improvement
Theories, hunches, best practices
Test a wider group
S
D
Test on a small scale
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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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Testing Done in Multiple Change Areas in Parallel
Aims Productivity Quality Coordination Access
RCI Team 4 Or 4th Change
RCI Team 3 or 3rd Change
RCI Team 2 or 2nd Change
RCI Team 1 Or 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 ImprovementExample
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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 Tool
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Data Analysis- Pareto Chart
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Data Analysis- Pareto Chart
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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?