SAFETY IN PRACTICE

Principles of Quality

Improvement

Understanding the

problem

Testing change

Collaborative learning May 17th 2015

Andrew Jones

Quality Improvement Specialist

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Safety in Practice A regional approach to quality improvement in primary care

What improvements have you made in your practice before?

What is Quality Improvement?

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It is not a tool for management

Quality Assurance

Standards/safety focused

Judgmental

If issue fixed assumes system

is excellent

Quality Improvement

Process focused

Positive

Driven by desire to do better

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It is done for a finite period of time

Acknowledgment: Bennett, 2015. Source: Juran, 1998.pg 95

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It is not just a way to save money

Source: http://www.nhsiq.nhs.uk/media/2541082/improvement_leaders_guide_-_measurement_for_improvement.pdf

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Quality improvement is Quality Improvement is the

techniques and methods used to

take us from where we are to where

we want to be.

Brandon Bennett

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It has many names Continuous Quality Improvement

Total Quality Management

Toyota Production System

Lean Six Sigma

Model for Improvement

What is the Model for Improvement?

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The Model for Improvement

Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009

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A clear explanation….

Source: https://youtu.be/SCYghxtioIY

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What are we trying to accomplish?

Program:

To enhance quality

improvement capability of

General Practices (GPs) within

the Auckland region, by

focusing on patient safety.

Your practice

Set a target relating to your

audit bundle once baseline

data collected

Aim

Understand the problem

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Every system is perfectly designed to get the results it gets

Paul Batalden

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What we think a process involves

Doctor orders

test

Doctor orders

test

Patient goes

for test

Patient goes

for test

Doctor receives results

Doctor receives results

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But really more like this

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Data analysis

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Time Series Plot of INR ResultsHealth New Lynn: 2014

NHI: BWP8299 GP Managed

Data Labels: Time Between Tests

09Sep1411Jul1404Jun1423Apr1411Mar1425Feb1411Feb1428Jan14

6

5

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Date

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Time Series Plot of INR ResultsHealth New Lynn: 2014

NHI: FUW4688 Nurse Managed

Data Labels: Time Between Tests

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Cause and effect

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Plus much more

Affinity Diagrams

Force field analysis

Five whys

Brainstorming

Problem solving

Support

Model for Improvement

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The Model for Improvement

Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009

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How do we know if a change is an improvement?

Data is power

Without it, don’t know progress

Measurement can be a dirty word

Measure

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Measuring for improvement is different

Source: https://youtu.be/SAo0O4jSe28

Mike Davidge 7 Steps to Measurement Edited.mp4

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Types of data

Accountability

For comparison and reporting

Research

For development of new knowledge

Characteristics of Accountability Characteristics of Research

Evaluative Blinded/Controlled

Adjust to reduce bias Eliminates bias

100% data ‘Just in case’ data

No hypothesis Fixed hypothesis

No tests One large test

No change focus Statistical tests

Results are public Subjects anonymous

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Types of data

Improvement

Are we moving closer to improving our service?

Characteristics of Improvement

Observational

Consistent bias

‘Just enough’ data

Flexible hypothesis

Run/Shewhart charts

Data for service only

Source Solberg et al, 1995

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Displaying data

Current situation(where we are)

Target (where we want to be)

Gap (how do we get there?)

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What changes can we make that will result in improvement?

To make improvement need to

test new ideas

To bridge gap between current

state and targetChange

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The Model for Improvement

Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009

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Insanity is doing the same thingover and over again expecting different results

Albert Einstein

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All improvement will require change, but not all changewill result in improvement!

Don Berwick

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Rapid Cycle Improvements

Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009

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Plan

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Do

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Study

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Act

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One builds on the next

Source: Langley et al, 2009

Very Small Scale Test (Qualitative/Quantitative Data)

Follow-up Tests

Tests under new conditions (Quantitative data)

Wide-scale tests of Change

Breakthrough Results

Hunches, Theories, Best Practices

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Sometimes doesn’t go to plan

Source: Ogrinc and Shojania 2013 Acknowledgement: Bennett, 2015

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Its worth it Some percentage of tests—perhaps 25 to 50 percent—is expected to result in no improvement, to “fail,” but to result in substantial learning nevertheless.”

Langley et al, 2009

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Documenting PDSAs

Challenging time wise Help you meet your Cornerstone requirements

Important to know what worked and what failed

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Documenting PDSAs

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Other ideas

Keep a note book with a page for each test

Have a tab on your spreadsheet with idea and result

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Quality improvement principles:

Improvement

Test changes

Understand Problem

Collect just enough data

Collaborative Learning

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Year One Collaborative

Warfarin

Medicine

Reconciliation

Results

Handling

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Year Two Collaborative

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Learning Sessions

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Learning sessions

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Story Boards

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Learning Sessions

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Often source for new ideas

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Steal Shamelessly

Ask questions PDSAs don’t have to be a new idea – steal shamelessly

Year one found lots of things worked or didn’t

Filter

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The beginning of a journey

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Medication Reconciliation

Lecture

Theatre

Ian Hutchby, Improvement Advisor, Ko Awatea, CMH

Diana Dowdle, Delivery Manager, KoAwatea, CMH

107 Opioid Prescribing

Vikas Sethi, Clinical Lead, Safety in Practice

Stuart Jenkins, Director Primary Care, WHDB/ADHB

Results Handling

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Campbell Brebner, Chief Medical Advisor, Primary Care, CMH

Dinner then breakouts

Andrew Jones, Quality Improvement Specialist, WDHB

Monique Davies, Project Lead, KoAwatea, CMH

Room 102 Warfarin Management

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References Associates in Process Improvement (2009). Model for improvement clip one. Retrieved from: https://youtu.be/SCYghxtioIY

Davidge, M (2011). 7 Steps to measurement for improvement. Retrieved from: https://youtu.be/SAo0O4jSe28

Juran JM, Blanton Godfrey A, Hoogstoel RE, Schilling EG (1998). Juran’s Quality Book (5th Edition). New York: McGraw-Hill Retrieved from: http://www.pqm-online.com/assets/files/lib/books/juran.pdf

Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP,(2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). San Francisco, California, USA: Jossey-Bass Publishers.

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References NHS Institute for Innovation and Improvement, (2005). Improvement Leaders’ Guide :Measurement for improvement,Process and systems thinking. Retrieved from:http://www.nhsiq.nhs.uk/media/2541082/improvement_leaders_guide_-_measurement_for_improvement.pdf

Ogrin,G. & Shojania, KG. (2013). Building knowledge, asking questions. BMJ Quality & Safety. Retrieved from: http://qualitysafety.bmj.com/content/early/2013/12/23/bmjqs-2013-002703.full.pdf+html

Solberg L, Mosser G, McDonald S, The three faces of performance measurement: improvement, accountability, and research. Joint Commission Journal on Quality Improvement, 1997; 23(3): 135-147